Provider Demographics
NPI:1275141525
Name:BERNALES, ROBIN (LAC)
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:
Last Name:BERNALES
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:ROBIN
Other - Middle Name:
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:1541 SUMNER ST
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-2542
Mailing Address - Country:US
Mailing Address - Phone:720-491-1171
Mailing Address - Fax:
Practice Address - Street 1:421 21ST AVE STE 8
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-1467
Practice Address - Country:US
Practice Address - Phone:720-491-1171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-22
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACU.0002555171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty